Home Telephone Number. I hereby request an unpaid leave of absence starting on Month Day Year through for the following reasons: Month Day Year Signature Date NOTE: When applying for an unpaid personal medical leave or unpaid job related medical leave, send the original request form and the originals of doctors’ notes directly to the Superintendent or designee. (Doctors’ notes must be hand signed by the doctors. Rubber stamped signatures are not acceptable.) Give a copy of this request form to your building principal. 0/00 Xxxxxxxx X XXXXXXXXX XXXX XXXXXX XXXXXXXX REQUEST FOR PROFESSIONAL LEAVE Date Submitted Name Date(s) Requested: Purpose for Request: Destination (City, State):
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Home Telephone Number. I hereby request an unpaid leave of absence starting on Month Day Year through for the following reasons: Month Day Year Signature Date NOTE: When applying for an unpaid personal medical leave or unpaid job related medical leave, send the original request form and the originals of doctors’ notes directly to the Superintendent or designee. (Doctors’ notes must be hand signed by the doctors. Rubber stamped signatures are not acceptable.) Give a copy of this request form to your building principal. 0/00 Xxxxxxxx X XXXXXXXXX XXXX XXXXXX XXXXXXXX 2/03 Appendix F FAIRFIELD CITY SCHOOL DISTRICT REQUEST FOR PROFESSIONAL LEAVE Date Submitted Name Date(s) Requested: Purpose for Request: Destination (City, State):
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